Файловый архив студентов. Файловый архив студентов.
1327 вузов, 5482 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:
Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_861_Библиотеки_им_академика_М_И_Перельмана.pdf
Скачиваний:
0
Добавлен:
31.08.2026
Размер:
36 Мб
Скачать
☆
►Содержание►

SURGERY

Preoperativepreparationincludesfulloralantibioticandmechanical bowelpreparation,prophylacticintravenousantibiotics,deepvein thrombosisprophylaxiswithstandardunfractionatedheparin,and pneumaticantiembolismstockings.Positioning,padding,andoperative preparationarethesameinhand-assistedsurgeryaswithmultiport laparoscopy.Patientsarepositionedinlithotomypositiononthe operatingroomtableusingAllen(AllenMedicalSystems,Inc.Acton, MA)orYellowfin(AllenMedicalSystems,Inc.Acton,MA)stirrups.Both armsaretunedonfoampads.Thechestispaddedwithfoampadsand thensecuredtothebedusing3-inchsilktape.Anorogastrictubeanda urinarycatheterareplaced.Therectumisirrigatedatthebeginningof thecasewithsalineandthenwithBetadinesolution.Transverse abdominisplaneblocksareusedselectivelyinadditiontoanaggressive preoperativeandpostoperativeenhancedrecoveryaftersurgery(ERAS) protocol.
Ifthepatienthashadpriorabdominalsurgery,initialperitonealaccess isachieved,dependingonthetype(s)ofpriorabdominalincisions. Diagnosticlaparoscopyisperformedlookingforevidenceof carcinomatosis,ascites,orlivermetastases.Additionalportsareplaced. Alowermidlineincisionismadetoaccommodatethehand-assistdevice. Theincisionforthedeviceneedstobe0.5cmlargerthantheglovesizeof thesurgeonwhosehandwillbeplacedinthedevice.
Inpatientswhohavenothadpriorsurgery,thebandaccessincisionis madeasthefirststepoftheprocedure.Oncethewoundcomponentof theGelport(AppliedMedical,RanchoSantaMargarita,CA)isplaced,a 10-/12-mmcameraportisplacedunderhand-directedcontrolinthe infra-orsupraumbilicalposition.Makingafistunderthesiteoftrocar placement,thetrocarcanbesafelyplacedwiththetrocartipenteringthe topoftheclosedfist.Thecapisthenplacedanduniform pneumoperitoneumto15mmHgachieved.A30-degree10-mmscope,5­mmscope,orflexibletipscopescanbeusedalternatively.Next,accessory trocarsareplaced.Threeotherports,two5-mmportsintherightandleft lowerquadrantsanda5-mmAirsealport(Conmed,Utica,NY)inthe rightupperquadrant(Fig.18-1),areused.TheAirsealportallowsfor excellentsmokeandplumeevacuationwithaverysteadyandstable pneumoperitoneum.Ifneeded,further5-mmaccessoryportscanbe placedforaddedretraction,butthisisrarelyutilized.
FIGURE18-1Typicalportplacementandhand
portplacementforlowanteriorresection.
ThepatientisthenplacedinsteepTrendelenburgposition,withtheleft sideelevated/rightsidedown.Thesurgeonstandsbetweenthepatient’s legswithamonitoratthepatient’sheadorleftshoulderforviewing.The assistantstandsonthepatient’srightsideandthecamerapersonabove theassistantontherightside.Asecondmonitoralongthepatient’sleft sidecanbemovedasneeded.Amedial-to-lateralapproachisemployed. Thelefthandinthehand-assisteddeviceelevatesthe sigmoid/rectosigmoidcolonanteriorly,placingthesuperior hemorrhoidalandinferiormesentericartery(IMA)pedicleonstretch (Fig.18-2).Amonopolarhookcauteryisusedtoincisetheperitoneum fromthebaseoftheIMAbehindthesuperiorhemorrhoidaltothe presacralplaneoverthesacralpromontory.Usingtwotothreefingersof thelefthandintotheperitonealincision,itispossibletoelevatethe superiorhemorrhoidalartery.Spreading/bluntdissectionwiththe
fingersandsharpdissectionwiththehookbytheassistantexposesthe ureterandgonadalvessels,whicharereflectedposteriorly.Aplaneis developedbehindtheIMApedicleandtheureterispushedlateraland posterior.AwindowiscreatedonthecephaladsideoftheIMAbeneath theleftcolicartery,creatinga“T”withtheIMAasthevertical component,thesuperiorhemorrhoidalastheinferiorlimb,andtheleft colic/IMVinferiormesentericvein(IMV)astheotherlimb.Oncethe anatomyisclearlyidentifiedandtheureterisoutoftheway,theIMA pedicleisdividedwithanenergy-sealingdevice,LigaSure(Coviden, Minneapolis,MN),(Fig.18-3).Intherareinstancethisdoesnotsecurely controltheIMA,anendoloopiseasilyplacedwiththecontrolofthe hand.
FIGURE18-2Elevationofsuperiorhemorrhoidal
arterypediclewithhandandhookdissection.
FIGURE18-3Inferiormesentericarterypedicle
division.
p.148
p.149
TheIMVisidentifiedatthebaseoftheleftcolonmesentery,lateralto thefourthportionoftheduodenum.Tentingupthemesenterywiththe lefthand,theassistantcreatesaplanebelowtheIMVattheinferioredge ofthepancreas.TheIMVisdividedwithanenergy-sealingdevice.Once thearteryandveinpediclesaredivided,thelefthandelevatesthe sigmoidanddescendingcolonmesentery,whichallowstheassistant bluntingreflecttheretroperitonealstructuresposteriorlyallthewayto thelateralabdominalwall.Usinghookcautery,thelateralattachments aretakendownalongthewhitelineofToldtfromthesigmoidtothe splenicflexure,connectingthetwodissectionplanes.
Thepatient’spositionischangedtoreverseTrendelenburg.Usingthe falciformligamentasthelandmark,thetransversecolonisgraspedwith thelefthandandthentheassistantgraspstheomentum.Theavascular planebetweentheomentumandthetransversecolonisincisedfor severalcentimeters.Thenthedeeperlayerofomentumisidentifiedanda windowismadebetweenthegastroepiploicvesselsandthetransverse colon,gainingaccesstothelessersac.Theremainingomentumis releasedfromthecolonuntilthesplenicflexureisfullymobilized. Switchingbackandforthbetweenthedescendingcolonfromtheleftside usingtheleftlowerquadrantportfordissectionandthetransversecolon fromtherightwillallowcompletemobilizationofthesplenicflexure. Retroperitonealattachmentsfromtheleftbranchofthemiddlecolicand inferioredgeofthepancreasarereleasedfromthebaseofsplenicflexure mesentery.
p.149
p.150
ThepatientisrepositionedinsteepTrendelenburgposition,withthe leftsideslightlyelevatedtoallowthesmallboweltobepositionedoutof thepelvis.Thenusingthelefthand,therectumiselevatedanteriorly, curlingthefingersbehindtherectum1–2cmfromtheavascularplane; usingthelefthandasaStMarksretractor(Fig.18-4).Thedissectionis performedusingmonopolarhookcauteryandusingeithera nontraumaticgrasperorsuctionforcountertension.Thedissectionis carrieddowntypicallytothecoccyxorWaldeyer’sfascia(Fig.18-5).Next, therectumisretractedtotherightandthelateraldissectionisperformed towardtheanteriorpelvicreflection.Therectumisthenretractedtothe
leftandthelateraldissectionisperformedontherightside.Lastly,the rectumisretractedcephaladandtheanteriorpelvicdissection
splayedlikea“peacesign”andusedtoelevatetheseminal vesicles/prostateinamaleandthevaginainafemaletoassistwiththe anteriordissection.Inthiscase,theassistantwillneedtoretractthe rectumcephalad.Atanypoint,theGelportcapcanberemovedand dissectioncanbeperformedthroughtheAlexisbaseusingnarrowlighted retractors.Oncetheintracorporealdissectionisperformedtoone’s satisfaction,theGelportcapisremoved.Themobilizedcolonis exteriorized.TheIMApediclethatwasligatedisidentifiedandstaying justaboveitthemesocolonisdividedtothelevelofthebarecolonwall usingadvancedbipolar.DependingonwhetheracolonicJ-pouchor straightanastomosisisplanned,thecolonisdividedusinganEndoGIA 80-mmstapler(Covidien,Minneapolis,MN)orusingapursestring clamp.IfacolonicJ-pouchisplanned,anapicalcolostomyismade6–7 cmfromthestapleline;andusingasinglefiringofaGIA80-mmstapler, a6.5-to7-cmJ-pouchiscreated.Alternatively,ifastraightanastomosis isplanned,anappropriatelysizedanvilisplacedintotheopenendofthe colonandthepursestringissecured.
FIGURE18-4Dissectioninposteriorpresacral
planewithhandretraction.
FIGURE18-5Posteriorpresacralplanewithhand
suspendingrectumanteriorly.
p.150
p.151
Thedistaltransectionsiteischosen,typicallyatthelevelofthebare rectumatthelevelofthelevatorswhenatotalmesorectalexcisionis performed,butattimeshigherifatumor-specificmesorectalexcisionis performed.ATA30greenstaplerisusedtodividetherectuminasingle firingunderdirectvisionandthespecimenisremovedandinspectedfor thedistalmarginsandqualityofthemesorectalexcision.
Typically,theanastomosisiscreatedunderdirectvisionthroughthe Alexisbase,butintracorporealanastomosisunderpneumoperitoneum canalsobeperformed.Oncetheanastomosisiscompleted,aflexible sigmoidoscopyisperformedwiththeanastomosis/pouchsubmerged undersalineandoccludedproximally,confirmingacircumferentially intact,well-vascularized,non-bleeding,andairtightanastomosishas beenachieved.If,forwhateverreason,thereisadefectorairleak dependingontheleveloftheanastomosis,theincisionallowsaccessto theanastomosis,whichcanbereinforcedorrepaired.
Ifaloopileostomyisperformed,theterminalileumcanbeidentified throughtheAlexisbaseandapointischosen40cmproximaltothe ileocecalvalve.Alternatively,itcanbeintracorporeallyidentifiedafter replacingtheGelportcap.Thececumisbroughtuptotheproposed stomasiteintherightabdomentoassureitwillreach.Theileostomysite ispreparedintheusualmanner.Oncethestomaispulledupthroughthe abdominalwall,anileostomyrodisplacedandpneumoperitoneum reestablishedsothatdirectvisualizationcanconfirmtheproper
orientationofthestoma.Theabdominalcavityisirrigated,themobilized colonisfollowedtothepelvistoassurethereisnotwist,andthecutedge examinedtoensurenosmallbowelhaspositioneditselfunderthecolon. Typically,theportsareremovedandthroughtheleftlowerquadrantport aJacksonPrattorBlakedrainisplacedintothepelvisbehindthepouch oranastomosis.
Thecameraportisclosedusing0VicrylsutureonaUR6needleand thePfannenstielincisionclosedbyclosingtheanteriorrectusfasciausing
1.0PDSsuture.Theskinatallportsitesandincisionsareclosedwith4.0 monocrylsubcuticularsutures.Benzoin,Steri-Strips,anddressingsare placed.TheileostomyisthenmaturedinaBrookemannerusinga3.0 chromicsutureandastomaapplianceisplaced.
POSTOPERATIVEMANAGEMENT
AnaggressiveERASprotocolusingmultimodalitypaintherapy,rapid dietadvancement,aggressiveambulation,andearlyremovalofdrains andcathetersshouldbeemployed.

COMPLICATIONS

Ahostofminorandmajorcomplicationscanoccurfollowingalow anteriorresectionregardlessoftheoperativeapproach.
Specificcomplicationsrelatingtothehand-assistedapproachare uncommonotherthanmaybeaslightlyhigherwoundinfectionratedue toaslightlylargerincisionrequiredforhand-assistedsurgerybecausethe averagesizeofextractionincisionsare7.5–8cm.
Othercomplicationsincludecardiopulmonary,urinarytract,andseptic complicationsrelatingtopelvicsepsisandanastomoticleak,whichare possibleregardlessofwhichminimallyinvasiveapproachisutilized.

RESULTS

Therearefewcomparativetrialscomparinghand-assistedlowanterior resectiontoeitheropenorlaparoscopicsurgery.However,thebenefitsof laparoscopicsurgeryseemtobepreservedbyhand-assistedsurgerywhile multiplestudieswouldsupportashorteroperativetimeusingsuchan approach.
Соседние файлы в папке Библиотека им академика М.И. Перельмана
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности